Maximizing inhibition of the renin-angiotensin system with high doses of converting enzyme inhibitors or angiotensin receptor blockers

Abstract

Most, but not all, studies performed with higher than recommended doses of either ACE inhibitors or particularly ARBs suggest that the approach is associated with a further decrement in protein excretion. The majority of patients probably attain their optimal therapeutic response at standard doses, but a smaller residual group has further therapeutic benefit. Since patients who would benefit from higher doses are not a prior identifiable, a temporary trial at higher doses of these drugs seems cogent in order to provide more robust antiproteinuric benefit to such patients. The cost of doing so in terms of side effects is low and warrants the approach. It must be noted that studies with hard endpoints are sorely lacking. Furthermore, there is a complete absence of trials that compare the administration of high doses of ACEs or ARBs to a combination of these two classes of agents given at conventional doses. It appears likely from the available experience that these two approaches would yield comparable results. © The Author [2008]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.